Packet B - Biological Sciences - University of California_ Irvine

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					                            Bio Sci 199 Undergraduate Research Program
                                  Packet B - Enrollment Procedures

You need to complete this packet if you are: (a.) working with Human Subjects; and/or (b.) at one of the following
designated UCI locations: (i.) Orange: UCI Medical Center, UCIMC Building 200, SOM Building 55, City Tower; (ii.) Irvine:
Gottschalk Medical Plaza, Joslin Diabetes Center, Santa Ana Family Health Center, Anaheim Clinic, Centerpoint Child
Development Center & School, Hewitt Hall (also known as Institution for Clinical Translational Science = only do packet if work is
with human subjects); (iii.) Long Beach: Veterans Administration Medical Center (education & research affiliation agreement);
(iv.) Costa Mesa: Fairview Developmental Center (teaching & research affiliation agreement).

Must have completed the Bio 194S Safety & Ethics course offered Fall, Winter, Spring & Summer Quarters.

Complete the following procedures & check the line when done:

      1)     Immunizations: Every student must meet with UCI Student Health Center to obtain Certificate of Completion.
             Make an appointment ASAP (949) 824-5301 or http://www.shs.uci.edu/. Please bring the next page and any
             immunization records you have when you meet with the nurse at UCI Student Health Center. Titer results take
             approximately 10 days. (Immunization fees apply where appropriate; Consult with UCI Student Health Center.) ** If
             you have your own insurance and have all required immunizations, you must obtain a copy of the record to take
             with you to your appointment at UCI Student Health Center.

      2)     The Biological Sciences 199 Proposal Form is on the web at http://www.bio.uci.edu/bio199. Complete the
             proposal, print, sign & obtain the faculty signature and submit it with the other documents.

      3)     Environmental Health & Safety Fire Extinguisher Training at the UCI Campus. You must turn in the Certificate
             of Completion with the packet documents.

      4)     Complete 3 computer based trainings: 2011 Annual Training (STUDENTS ONLY), HIPAA, Biomedical
             Investigators-Basic Course. Print verification.

      5)     Provide a photocopy of your personal health insurance or USHIP card.

      6)     Read and sign, where appropriate, ALL enclosed forms in the packet. The Department Orientation Record also
             requires the signature of the faculty sponsor or the research supervisor. All signatures must be obtained before
             your packet is complete.

      7)     Complete the top student portion of the Biological Sciences 199 Assignment Record.

      8)     Return the completed Biological Sciences 199 Research Packet B to the Biological Sciences Student Affairs Office
             (1011 Biological Sciences III). Recommendation: Make a copy for your records. Students need to meet with
             either Kristin Fung or Sherry Ong by the enrollment deadline. The deadline for fall, winter, spring, and 10-
             week summer session enrollment is always the Friday of 3rd week of each quarter. The deadeline for Summer
             Session 1 & 2 is the Friday of first week of each session. For fall, winter, and spring: Enroll via WebReg after
             submitting the packet for the academic year. For Summer Session enrollment: Please go to
             www.summer.uci.edu Go to “Student Services”. Click on “Forms”. Print “Bio 199 Independent Research Form”.
             Have your Bio 199 faculty sponsor signed, bring it to us along with the Bio 199 Packet, we will sign for the dean.
             You then take this form to Summer Session and they create the course code and enroll you.

____ 9)      Upon completion of all the above requirements, UCIMC Human Resources issues a Bio 199 photo ID badge.
                a) Wear this ID badge while performing research duties on site.
                b) Turn in the ID badge at the end of the research assignment.


____ 10)     Quarterly summary reports: End of the quarterly summary reports are due on Monday of 10th week of each quarter.
             It is electronic submission only. Please go to www.bio.uci.edu/bio199

                 Questions? Contact Kristin Fung ksfung@uci.edu or Sherry Ong at ongsh@uci.edu


                             School of Biological Sciences Student Affairs Office & School of Medicine
                                                   University of California, Irvine
                                                       Irvine, CA 92697-1460
                                                                                                                         09/09/11
                University of California Irvine Medical Center Sites
                     Bio Sci 199 Vaccination Requirements
The UC Irvine College of Health Sciences in accordance with UC Irvine Medical Center Occupational Health
Department recommendations require documentation of the following vaccinations and/or antibody titer/s prior
to working (including administrative) with School of Medicine Faculty Members at UC Irvine Medical Center
sites:
1. Hepatitis B Series Vaccine (Series of 3)
   Hepatitis B Titer, post completion of Hepatitis B Vaccine (documentation within last 5 years.)
2. Measles, Mumps & Rubella Vaccine (MMR)
3. Varicella (Chicken Pox) Vaccine (Series of 2) or
   Varicella Titer (current within the last 5 years)
4. Tetanus, Diphtheria, Pertussis (Tdap) (current within the past 2 years.)
5. TB Skin Test (Valid one year)
   Chest X-Ray required when skin test is positive. (Valid four years.)


Student: Last Name:                                      First Name:                            Student ID#

Enrollment Quarter: _______________Student Health Center Interviewer:

ο TB Skin Test: (annual)             Date Given:                                          Signature:
     TB Chest x-Ray: (4 years) Date Given:                                                Signature:

ο Hepatitis B Vaccine: (series of 3)         Date Given/reviewed:                         Signature:
                                             Date Given/reviewed:                         Signature:
                                             Date Given/reviewed:                         Signature:

    Draw blood for serology: Date sample collected:                                       Signature:

    Hepatitis B Titer Result*                                                       Date/Signature:
    NOTE: Give Hep B booster (1 shot) when titer is negative, repeat titer.
    Hep B Vaccine-booster: Date booster administered (1):                                 Signature:
    Draw blood for serology: Date sample collected:                                       Signature:
    Repeat Hepatitis B Titer Result*                                                Date/Signature:


ο Measles, Mumps & Rubella Vaccine: Date Given/reviewed:                                  Signature:
                                                 Date Given/reviewed:                     Signature:
    Draw blood for serology: Date sample collected:                           Titer Results* _______________________________
    Negative MMR antibody test—Date vaccine administered:                                 Signature:

ο Varicella Vaccine (series of 2)           Date given/reviewed (1):                      Signature:
                                             Date given/reviewed (2):                     Signature:
    Draw blood for serology. Date sample collected:                                       Signature:
    Varicella (Chickenpox) Titer Result*                                             Date/Signature:


ο Tetanus, Diphtheria, Pertussis [Tdap]: Date Given/Reviewed:                             Signature:

*   All serology results must have a copy of the complete lab report attached. The Student Vaccination Certificate must show the name of
    the Laboratory performing the test. The Student must have a titer that indicates a value above the minimum standard set by the testing
    Laboratory.
                             School of Biological Sciences Student Affairs Office & School of Medicine
                                                   University of California, Irvine
                                                       Irvine, CA 92697-1460
                                                                                                                                05/05/09
       MANDATORY FIRE EXTINGUISHER SAFETY TRAINING SESSIONS


   YOU MUST BE ON TIME AT THE SESSION TO RECEIVE CREDIT FOR COMPLETION OF THE
        COURSE. TURN IN THE CERTIFICATE OF COMPLETION WITH THE PACKET.


If you are not a current UCI student employee or have not logged in to UC Learning Center before, you
must submit the “Student & Affiliate Access Request Form”. Access approval may take couple days. If
you already have access to UC Learning Center, start from Step #8.

       1. Go to http://uclc.uci.edu/
       2. Under STUDENT & AFFILIATE ACCESS, click on “Student & Affiliate Access Request Form”
       3. Enter your UCInetID and password
       4. Click on icon to “Search Supervisor”
       5. First name type in “Sherry”. Last name type in “Ong”. Click “Search”
       6. Once you’ve identified the supervisor, it should bring you back to the previous page
       7. Choose “4 - All Other Campus Student”. Click “Submit”
       8. When you have access to UC Learning Center, go to http://uclc.uci.edu/
       9. Click on “LOGIN”. Enter your UCInetID and password.
       10. Click on “COURSE SEARCH”
       11. Choose “Fire Extinguisher Safety”
       12. Click “Register”
       13. Choose one of the ILT Class. Click “Submit” at the bottom of the page.
       14. To print a Certificate of Completion: Go to http://uclc.uci.edu/
       15. Click on “TRANSCRIPT”
       16. Print & submit with the rest of the Packet B.



                    Sessions conducted at Environmental Health & Safety Building
                                            UCI CAMPUS
                                    4600 Health Sciences Road
                                      Conference Room 122B
                                           (949) 824-6200
                           Instructors: Alan Sahussanun and Steve Eros



                                LAST FIRE SAFETY TRAINING SESSION:
                               7:00AM ON THE DAY OF THE DEADLINE!!!



                              BIO 199 ENROLLMENT DEADLINE:
The add deadline for fall, winter, spring, and 10-week summer session enrollment is always the
                              Friday of third week of each quarter.
 The add/drop deadline for Summer Session 1 & 2 is the Friday of first week of each session.



                      School of Biological Sciences Student Affairs Office & School of Medicine
                                            University of California, Irvine
                                                Irvine, CA 92697-1460
                                                                                                  01/27/12
                            3 Computer Based Training Courses

1.    UC Learning Center: 2011 Annual Training (STUDENTS ONLY)

If you are not a current UCI student employee or have not logged in to UC Learning Center before, you must
submit the “Student & Affiliate Access Request Form”. Access approval may take couple days. If you
already have access to UC Learning Center, start from Step #8.

        1.  Go to http://uclc.uci.edu/
        2.  Under STUDENT & AFFILIATE ACCESS, click on “Student & Affiliate Access Request Form”
        3.  Enter your UCInetID and password
        4.  Click on icon to “Search Supervisor”
        5.  First name type in “Sherry”. Last name type in “Ong”. Click “Search”
        6.  Once you’ve identified the supervisor, it should bring you back to the previous page
        7.  Choose “4 - All Other Campus Student”. Click “Submit”
        8.  When you have access to UC Learning Center, go to http://uclc.uci.edu/
        9.  Click on “LOGIN”. Enter your UCInetID and password.
        10. Click on “COURSE SEARCH”
        11. Choose “2011 Annual Training (STUDENTS ONLY). Click “Register”
        12. Now all the modules that's required for that training would show (with a check on its left hand
            side). You cannot check or un-check it. Click on "Submit" at the bottom.
        13. This should bring you to a page that shows you have registered for this particular training (total 3
            modules: Workplace Safety, Workplace Security, and Health & Wellness). On the left column,
            there is a “Start” with a green arrow. You can click on it to start your modules.
        14. Print transcript/Diploma & submit with the rest of the Packet B.

2.    UCI IRB Research Requirements
UCI IRB Training Tutorials (HIPPA)
Go to: http://apps.research.uci.edu/tutorial/
     HIPAA Research Tutorial

You will be prompted to login with your UCInetID and password. Complete the required modules. Print the
Tutorial Verification.

Print HIPAA Tutorial Verification for your Bio Sci 199 packet & submit it with the other required
Bio199 documents to: Kristin Fung or Sherry Ong at Biological Sciences Student Affairs Office (1011
Biological Sciences III Building).

What Does the Privacy Rule Have To Do With Research?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule and Security
Regulations affects only that research which uses, creates, or discloses Protected Health Information (PHI).
Researchers use, access, and disclose PHI to carry out a wide range of health research studies. The Privacy
Rule protects PHI while providing ways for researchers to access and use PHI when necessary to conduct
research. In general, there are two types of human research that would involve PHI:
        • Protocols involving review of existing medical records as a source of research information.
            Retrospective studies, such as chart reviews, often do this. Sometimes prospective studies do it
            also, for example, when they contact a participant's physician to obtain or verify some aspect of
            the participant's health history.
        • Protocols that create new medical information because a health care service is being performed as
            part of the research, such as testing of a new way of diagnosing a health condition or a new drug
            or device for treating a health condition. Virtually all sponsored clinical trials that submit data to
            the U.S. Food and Drug Administration (FDA) will involve PHI.


              School of Biological Sciences Student Affairs Office & School of Medicine
                                    University of California, Irvine
                                        Irvine, CA 92697-1460
                                                                                                         02/11/11
3.   Instructions on Collaborative Institutional Training Initiative (CITI)

The CITI Program is a subscription service providing on line research ethics education to the research
community. Students will complete the required training tutorial on CITI.

         Go to www.citiprogram.org
          st
         1 page: Click on “New Users Register Here”




          nd
         2 page: Q1. Choose – University of California, Irvine. Q2. Use your UCInetID as your username
         if possible. Select a different username only if your UCInetID is not available. Use a password
         that is different from your UCI account. Remember that password!!! Q3. Choose a security
         question and type in answer. Q4. Enter your name as it appears on the UCI records. No nick
         names. Q5. Use UCI email address as Preferred Email. Q6. Choose “No” - not requesting
         CME/CEU credits. Q7. Choose “No”. No need to complete a course survey. Then, click
         “Submit”
 rd
3 page (must provide an answer in all fields marked with an asterisk* ) :

         Institutional email address – enter your UCI email address
         Role in human subjects research – “Student Researcher - Undergraduate”
         Office Phone – your contact phone number
         Which course do you plan to take – “Basic Human Research Protections”
         Click “Submit”




 th
4 page: Which training course do you wish to complete?

         Choose “Enroll in the Human Research Protection Course”; click “Next”
 th
5 page: Which Human Research Protections (HRP) Course would you like to complete?

         Choose “I need to complete the Basic HRP Course for Biomedical Investigators”

         Click “Next”




 th
6 page: If you want to add the training requirements for another institution, you may do it now.
You can click either “Yes” or “No”. In most cases, the answer would be “No” for most students at
this time.
 th
7 page, click “Enter” under Status to begin or continue the course – you can stop and restart it
whenever you like. The course should say “Biomedical Investigators, Basic Course”

Complete tutorial. The status on this page must say “Completed” or “Passed”. Print this page.
 WHAT SHOULD YOU DO IF YOU ARE ACCIDENTALLY EXPOSED
             TO BLOOD OR BODY FLUIDS?

1. Exposure
   Exposure means you have had a specific contact from blood or body fluid to
   your eye, mouth, other mucous membrane, or non-intact skin; or you have
   received a puncture from a contaminated needle or sharp instrument.

2. First Aid
   a. For a simple exposure without any other injury, immediately remove your
      contaminated clothing;
  b. For any eye exposure, immediately flush with water for 15 minutes;
  c. For a non-broken skin exposure, immediately wash well, using friction for
     at least 15 seconds, with antiseptic soap and water.
  d. For a broken skin exposure, immediately wash well with antiseptic soap
     and water.

3. After giving yourself first aid, immediately, notify the unit SUPERVISOR.
   If s/he is not available, DO NOT DELAY TREATMENT. Immediately notify the
   Campus Student Health Service by calling: 949/824-5302 or 949/824-5304.

4. TREATMENT
   07:30-17:30 M-F For information & instructions for treatment, immediately:
   Go to or call the Irvine Campus Student Health Service at 949/824-5302 or
   949/824-5304. Go to or call the UCI Medical Center Occupational Health
   Service at 714/456-8300.
  After hours and weekends:
  DO NOT DELAY TREATMENT! Inform your supervisor of any illness or injury
  the following day or as soon as possible. Your supervisor must complete the
  proper paperwork and notify the Campus Student Health Service within 24
  hours after s/he receives your notification of an accidental exposure.
  Seek treatment at your insurance’s designated medical facility.                            Notify the
  Campus Student Health Service the next day.

5. FOLLOW-UP
   A subsequent follow-up by the medical provider includes evaluation of any
   related illnesses. After initial medical intervention, a copy of the medical
   provider’s written report will be made available to you. You will be notified of
   the results during a medical follow-up visit.
                 School of Biological Sciences Student Affairs Office & School of Medicine
                                       University of California, Irvine
                                           Irvine, CA 92697-1460
                                                                                                 11/21/06
              University of California Irvine Medical Center Dress Code

Medical Center staff (employees, faculty, residents, physicians, volunteers, students and others who represent
the Medical Center) shall present a clean, neat, well-groomed appearance that conveys respect for oneself, one’s
fellow employees, the public and the Medical Center during work hours. The attire shall be appropriate to the
individual’s occupation/profession and shall also contribute to the highest standard of hospital hygiene, patient
expectation, and employee safety. Radical departure from conventional dress or grooming standards shall not be
permitted. The minimum standards of dress and appearance are as follows:
1.     Identification badges shall be worn clearly visible at or above the waist at all times. These badges
       shall identify the name and position of the wearer. Identification badges are required by Title XXII (22) of
       the California Administrative Code, Section 70721 D. which states in part "all employees of the hospital
       having patient contact, including students, interns and residents, shall wear an identification tag
       bearing their name and title". Because all staff may come in contact with patients, if even for purpose of
       providing directions, there shall be no exceptions to this provision.
2.     Hair on the head or face shall be clean & trimmed; controlled in an appropriate manner so as not to
       interfere with job duties. Color & style shall remain conservative. Unless required for safety, hats shall not
       be worn.
3.     Clothing shall be neat and clean. Any questions regarding apparel shall be decided by the supervisor of
       the individual in favor of conservative standards. Departments may grant exceptions to the below examples
       for employees who, prior to coming on duty, are required to change into and remain in uniforms and scrubs.
       Examples of unacceptable apparel include:
       a.    Beach sandals, thongs, spike heels or bare feet;
       b.    Floor length dresses, indiscreet hemlines or fishnet stockings;
       c.    T-shirts, shirts with logos/slogans, sweatshirts. Exceptions to this would be UCI Medical Center T-
             shirts worn in conjunction with University sponsored events.
       d.    Torn or frayed garments;
       e.    Shorts, or jeans, regardless of color;
       f     Garments made of "dress denim" are acceptable when in compliance with this policy.
4.     Professional attire for men shall consist of a dress shirt with sleeves and collar. Departmental policy shall
       determine if neck ties are required.
5.     Shoes shall be clean, in good repair and appropriate for the work to be performed. Sling-back shoes (with
       straps across the heel) are acceptable.
6.     Safety shoes, hard hats or other safety garment may be required, as appropriate, for the work to be
       performed.
7.     Jewelry and other accessories shall be minimized and may not be worn where safety or health standards
       would be compromised. No more than two earrings per ear shall be worn. Body piercing anywhere other
       than the ear shall not be displayed.
8.     Large or offensive tattoos must be covered at all times. Any questions regarding the interpretation of this
       requirement shall be decided by the supervisor of the individual in favor of conservative standards.
9.     In consideration of the comfort and possible allergic reaction of others, perfume and cologne should be
       minimal. Minimal is defined as undetectable by customers or co-workers.
10.    Fingernails must be clean and trimmed. Long fingernails present a safety hazard to self and others, and
       should extend no longer than ½" beyond the tip of the finger. Nail polish should not be chipped or peeling
       and the color should be subtle (no bright neon, black or fluorescent shades).
       For all hands-on direct patient care providers (including, but not limited to: Registered Nurses, Licensed
       Vocational Nurses, Nurse Practitioners, Nursing Assistants, Therapists, Technicians, Technologists,
       Physicians, Physicians Assistants and students; also applies to any additional job categories that routinely
       provide hands-on care to patients):
       a.      Artificial fingernails are not to be worn. Nail polish is permitted but anything applied to natural nails
               other than polish is considered an enhancement. This includes, but is not limited to, artificial nails,
               tips, wraps, appliqués, acrylics, gels and any additional items applied to the nail surface.
       b.      Natural fingernails will be maintained at a nail length not to exceed ¼ inch beyond fingertips.

                        School of Biological Sciences Student Affairs Office & School of Medicine
                                              University of California, Irvine
                                                  Irvine, CA 92697-1460
                                                                                                                11/21/06
                     BIO SCI 199 STUDENT ASSIGNMENT RECORD
Completion of this form is required for all Biological Sciences 199 Biomedical students who are assigned either
on a temporary or a permanent basis. The student completes the form above the line; and a Biological Sciences
Student Affairs Office staff member completes the form below the line.

Please print the following information legibly:
Student Name: _____________________________________ Student ID: ___________________________
Project Title: ______________________________________________________________________________
Does your Bio 199 research involve one of the following?
(1) Human Subjects:       No        Yes, IRB (Institutional Review Board) #: _____________________________
(2) Animals:      No        Yes, IACUC (Institutional Animal Care & Use Committee) #: ____________________
(3) Bench research only --- no human or animal subjects:          No        Yes
   If yes, please provide a brief summary: ______________________________________________________
    ______________________________________________________________________________________
(4) Other: ________________________________________________________________________________

Research Location: _________________________________________________________________________

Research Site Phone #: _____________________________________________________________________

Student E-Mail Address: _______________________________ Student Phone #: ______________________

Faculty Sponsor: ______________________________________ Department Name: ____________________

Faculty E-Mail Address: ________________________________ Faculty Phone #: ______________________

Research Supervisor (if different from Sponsor): _____________________ Phone #: ____________________

_________________________________________
               This section is completed by the Biological Sciences Student Affairs Office :
I certify this student has completed the following requirements and the supporting documentation is on file in the
Biological Sciences Student Affairs Office:

o Bio 199 Protocol Proposal: ___________________             o 2011 Annual Training ________________________
o Department Orientation Record: _______________             o HIPAA Research Tutorial: _____________________
o Waiver of Liability with Academic Year Signed              o Biomed Invest Basic Course: ___________________
o Confidentiality Agreement signed: ______________           o Fire Extinguisher Class Certificate: _______________
o Immunization Certificate: _____________________            o Bio 194S Completed: __________________________
o Health Insurance Documentation: ______________             o Photo ID Badge Issued to Student: _______________

Comments: _______________________________________________________________________________

BSSAO Signature: __________________________________________ Date: _________________________
                        School of Biological Sciences Student Affairs Office & School of Medicine
                                              University of California, Irvine
                                                  Irvine, CA 92697-1460
                                                                                                           02/11/11
                                    DEPARTMENT ORIENTATION RECORD
                                      BIO 199 RESEARCH STUDENTS

STUDENT NAME: _________________________________________________________________________________
                              Last                      First


   REVIEWED           STUDENT TRAINING TOPICS
                      Assigned research duties
                      Scheduled of days in the department
                      Dates of Assignment
                      Healthcare Facility Dress Code
                      ID Badge must be worn at all healthcare sites & turned in at the end of the assignment
                      Fire Safety Equipment Location in Department
                      Fire Extinguisher Training Class completed
                      Personal Health Safety
                      Person to notify in case of emergency recorded below:
                      Name:
                      Relationship:
                      Phone Number:

I certify that I have received the information and training as described above in the areas checked.


Student Signature: ______________________________________________________

DEPARTMENT VERIFICATION: All of the above elements have been reviewed with the student, including any safety
issues specific to the student’s assignment and I reviewed the DEPARTMENT ORIENTATION RECORD for completeness.
The student’s questions were answered. The student will not be conducting assignments that involve handling
human blood, body fluid/s or tissue.


Faculty or Research Supervisor Signature: _______________________________________                       Date: _______________




                          REPORTING SECURITY INCIDENTS/BREACHES
                  AT UC IRVINE MEDICAL CENTER AND PATIENT CARE LACTIONS

All potential breaches or unauthorized access or disclosures of patient information must be reported to the Compliance
Office immediately upon discovery in order to ensure compliance with State and federal reporting requirements.

Loss or theft of any computing device including a flash drive that contain patient information MUST be reported
immediately to the UC Irvine Security Department and the Security Information Officer

For all other suspected breaches, complete an online incident report form on the main intranet page,
(https://uciincident.ucdmc.ucdavis.edu/IR/?s=uci) and notify one of the following:

    •    The Compliance & Privacy Officer (714 456-3672)

    •    Information Security Officer (714 456-7349)

    •    Confidential Compliance Alert-line (888-456-7006)

I understand this training and agree to comply with safe work practices in my work area.



Student Signature: ______________________________________________________                       Date: _____________________


                            School of Biological Sciences Student Affairs Office & School of Medicine
                                                  University of California, Irvine
                                                      Irvine, CA 92697-1460
                                                                                                                     07/22/11
                                     WAIVER & RELEASE OF LIABILITY
                                                  AND
                              ACKNOWLEDGMENT OF THE ASSUMPTION OF RISK
                         199 BIOLOGICAL SCIENCES INDEPENDENT STUDY STUDENTS

I acknowledge that by enrolling in the 199 Biological Sciences Independent Study course, I may be exposed to a
variety of pathogenic viral and bacterial vectors of disease. I further understand that I may be exposed to infectious
or contagious diseases resulting from my direct or indirect contact with patients and/or human body fluids. Included
in, but not limited to, this exposure are the bacteria or viruses which cause Hepatitis A, B and C, AIDS, measles,
mumps, rubella and whooping cough; the mycobacterium causing tuberculosis; the microorganisms causing
influenza, conjunctivitis, impetigo; the common cold and lice. Exposure to these infectious agents, and other
infectious agents not listed here, could result in illness, disability, morbidity and/or death, the risks of which I am
willing to assume and for which I am wiling to release The Regents of the University of California and its agents,
officers and employees from liability as stated on this document.
I understand it is my personal responsibility to contact a physician if I have any personal or medical concerns
regarding my participation in the 199 Biological Sciences Independent Study course. I further understand that I am
strongly advised to contact a physician if I have any of the following conditions or am taking any of the following
drugs:
                                   •   Diabetes
                                   •   Organ or tissue transplant
                                   •   Cancer
                                   •   Chronic infectious disease
                                   •   AIDS or HIV positive status
                                   •   Any –immunocompromising disease
                                   •   Pregnancy
                                   •   Steroids
                                   •   Chemotherapeutic drugs for cancer
                                   •   Any other drugs which impair my immune system

I further understand the above list of conditions, diseases and drugs is not all inclusive, but merely illustrative. As a
student, I further understand I am not covered by the worker’s compensation program and that were I to incur any
illness while enrolled in this course I will not receive any from of compensation.
I agree to release and forever discharge The Regents of the University of California, its officers, agents and
employees, both in their individual capacities and by reason of their relationship to The Regents of the University of
California from any and all claims and demands whatsoever which I or my heirs, representatives, executors or
administrators, have or may have against The Regents by reason of any accident, illness or injury or other
consequences however caused, except through negligent or intentional acts or omissions of The Regents of the
University of California, Its officers, employees or agents arising or resulting directly or indirectly from my
participation in the 199 Biological Sciences Independent Study course for the academic year.
By signing this statement, I acknowledge that I have read and understand the information on these two pages and
agree to the conditions contained therein, including the release of liability against the Regents of the University of
California, and acknowledge the assumption of the risks of participating in the 199 Biological Sciences Independent
Study Courses.

____________________________________________________
Student Signature                                                  Student ID Number                  Academic Year


____________________________________________________
Student Name Printed                                               Date



Signature of Parent or Guardian for Students under 18 years                                           Date

_________________________________________________________________________
Name of Parent or Guardian Printed



                         Waiver and Release of Liability and Acknowledgement of Assumption of Risk
                                               University of California, Irvine
                                                   Irvine, CA 92697-1460
                                                                                                                11/21/06
              University of California, Irvine Healthcare
              Confidentiality Agreement



Applies to all UC Irvine Healthcare “workforce members” including: employees; medical staff and other health care professionals; volunteers; agency,
temporary and registry personnel and trainees; house staff, students and interns (regardless of whether they are UC Irvine trainees or rotating through UC
Irvine Healthcare facilities from another institution).

It is the responsibility of all UC Irvine Healthcare workforce members, as defined above, including employees, medical staff, house staff, students and
volunteers to preserve and protect confidential patient, employee and business information.

The federal Health Insurance Portability and Accountability Act (the “Privacy Rule”), the Confidentiality of Medical Information Act (California Civil Code
§ 56 et seq.), and the Lanterman-Petris-Short Act (California Welfare & Institutions Code § 5000 et seq.) govern the release of patient identifiable
information by hospitals and other health care providers. The State Information Practices Act (California Civil Code sections 1798 et seq.) governs the
acquisition and use of data that pertains to individuals. All of these laws establish protections to preserve the confidentiality of various medical and personal
information and specify that such information may not be disclosed except as authorized by law or the patient or individual.

Confidential Patient Care Information includes: Any individually identifiable information in possession of or derived from a provider of health care
regarding a patient’s medical history, mental or physical condition or treatment, as well as the patients’ and/or their family members’ records, test results,
conversations, research records, and financial information. (Note: this information is defined in the Privacy Rule as “protected health information”.)
Examples include, but are not limited to:
     •    Electronic and paper medical and psychiatric records including photos, videos, diagnostic results, therapeutic reports, and laboratory and
          pathology samples;
     •    Patient insurance and billing records;
     •    Department based computerized patient data;
     •    Alphanumeric radio pager messages;
     •    Visual observations of patients receiving medical care or accessing services; and
     •    Verbal information provided by or about a patient.

Confidential Employee and Business Information includes, but is not limited to the following:
    •    Employee home telephone number and address;
    •    Spouse or other relative names;
    •    Social Security number or income tax withholding records;
    •    Information related to evaluation of performance;
    •    Other such information obtained from the University’s records which if disclosed, would constitute an unwarranted invasion of privacy; or
    •    Disclosure of confidential business information that would cause harm to UC Irvine Healthcare.

Peer Review and risk management activities and information are protected under California Evidence Code Section 1157 and the attorney client privilege.

I understand and acknowledge that:
     1.        I shall respect and maintain the confidentiality of all discussions, deliberations, patient care records and any other information generated in
               connection with individual patient care, risk management and/or peer review activities.
     2.        It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, proprietary information and
               other confidential information relating to UC Irvine Healthcare and its affiliates, including business, employment and medical information
               relating to our patients, members, employees and health care providers.
     3.        I shall only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by
               law, and in a manner which is consistent with officially adopted policies of UC Irvine Healthcare, or where no officially adopted policy
               exists, only with the express approval of my supervisor or designee. I shall make no voluntary disclosures of any discussion, deliberations,
               patient care records or any other patient care, peer review or risk management information, except to persons authorized to receive it in the
               conduct of UC Irvine Healthcare affairs.
     4.        UC Irvine Healthcare Administration performs audits and reviews patient records in order to identify inappropriate access.
     5.        My user ID is recorded when I access electronic records and that I am the only one authorized to use my user ID. Use of my user ID is my
               responsibility whether by me or anyone else. I will only access the minimum necessary information to satisfy my job role or the need of the
               request.
     6.        I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss information outside of
               the work place or within hearing of other people who do not have a need to know about the information.
     7.        I understand that any and all references to HIV testing, such as any clinical test or laboratory test used to identify HIV, a component of HIV,
               or antibodies of antigens to HIV, are specifically protected under law and unauthorized release of confidential information may make me
               subject to legal and/or disciplinary action.
     8.        I understand that the law specifically protects psychiatric and drug abuse records, and that unauthorized release of such information may
               make me subject to legal and/or disciplinary action.
     9.        My obligation to safeguard patient confidentiality continues after my termination of employment with the University of California.

I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the
above terms. In the event of a breach or threatened breach of the Confidentiality Agreement, I acknowledge that the University of California may, as
applicable and as it deems appropriate, pursue disciplinary action up to and including termination from the University of California.


Dated: _________________ Signature: ______________________________________

                                        Print Name: _____________________________________

                                        Department: _____________________________________
UC Irvine Healthcare 02/11/11

				
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